Morning Handover of On-Call Issues

Abstract

IMPORTANCE Handover is the process of transferring pertinent patient information and clinical responsibility between health care practitioners. Few studies have examined morning handover from the overnight trainee to the daytime team.OBJECTIVE To characterize current morning handover practices in 2 academic medical centers by assessing the frequency of omissions of clinically important overnight issues during morning handover and identifying factors that influence the occurrence of such omissions. DESIGN, SETTING, AND PARTICIPANTSA prospective, point-prevalence study was conducted in the general internal medicine wards of 2 tertiary care academic medical centers in Toronto, Ontario, Canada, in 2012 and 2013. Participants included on-call third-year medical students and first-and second-year residents. MAIN OUTCOMES AND MEASURESCompleteness of morning handover of clinically important overnight issues identified using a targeted medical records review and processes of morning handover characterized by direct observation. RESULTSWe identified 141 clinically important overnight issues during 26 days of observation. The on-call trainee omitted 40.4% (95% CI, 32.3%-48.5%) of clinically important issues during morning handover and did not document any information in the patient's medical record for 85.8% (95% CI 80.1%-91.6%) of these issues. By univariate analysis, running the list patient-by-patient (ie, the entire team discusses each patient) (OR, 4.32; 95% CI, 1.94-9.60; P < .001) and using a dedicated handover location (OR, 2.61; 95% CI, 1.30-5.22; P = .007) positively correlated with handover of an issue taking place, whereas distractions in the meeting area inversely correlated with the likelihood of handover of an issue taking place (OR, 0.96 for every increase in 1 distraction; 95% CI, 0.93-0.98; P = .002). Using a multivariate mixed-effects model, only running the list remained as an independent predictor of the handover of an issue (OR, 3.80; 95% CI, 1.25-11.49; P = .02). CONCLUSIONS AND RELEVANCEOn-call trainees omit numerous clinically important issues when handing over to the daytime team. Training programs should introduce educational activities and workflow changes, and provide dedicated time and a distraction-free environment, to improve handover of on-call issues.

Transitions of Care: Complications and Solutions

“…Omissions of clinically important on-call issues by fatigued on-call residents when transferring care to the daytime team at the end of shifts are major contributors to miscommunications and can result in care implementation delays and adverse events [16]. Insuicient handof communication result in incomplete, inaccurate, and omited data and efectuate informational ambiguities between the departing and oncoming providers.…”

“…Research by Devlin et al demonstrated that only 14% of clinically important issues from the overnight clinical shifts had an accompanying progress note from the on-call trainee in the patient's medical record [16]. Discontinuity of care secondary to inefectual handofs has been correlated with longer hospital stays and increased costs [3].…”

“…On-call trainees fail to hand over numerous clinically important issues to the daytime team and frequently do not document their assessments and responses to the on-call issue in the medical records. These omissions have the potential to cause unnecessary delays and may result in a lack of follow-up for important patient issues [16].…”

“…House staf judge that strategies for handof standardization most valuably improve quality of handof and resident physician satisfaction with transition of care [16]. Most emergency medicine (EM) residency directors agree that standardized handofs have the potential to reduce errors during transition of care, yet the majority of EM residency programs do not have a policy or a procedure regarding handofs [17].…”

“…Didactic and interactive sessions teach key principles, and communication techniques of verbal and writen handofs utilizing mnemonics and checklists have shown to beneit in improving quality and standardization of handof communications [19]. The SBAR mnemonic beneits handof communication because of its simplicity, it provides a consistent framework for handof scenarios, it can be utilized by diferent care providers, and it emphasizes on the clinician's assessment and response [16,22]. Checklists have been efective in several diferent clinical setings in terms of decreasing medical errors and morbidity; utilization of checklists have the potential to improve the transfer of care process as well [23,22].…”